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See “Challenge of Meeting Fellowship Procedural Guidelines in Therapeutic Endoscopy and Liver Biopsy” by Lentze on page 3 and “Challenges in Meeting Fellowship Procedural Guidelines in Pediatric Therapeutic Endoscopy and Liver Biopsy” by Lerner et al on page 27.

Endoscopic procedures play important diagnostic and therapeutic roles in the practice of pediatric gastroenterology. The North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN)'s guidelines for training in pediatric gastroenterology, published in 1999, were updated in 2013 (1,2). These guidelines include recommendations about the minimum number of procedures that should be performed to achieve competency during fellowship training.

In this issue of the Journal of Pediatric Gastroenterology and Nutrition, Lerner et al (3) discuss challenges in meeting the number of recommended procedures. The authors collected data from 12 pediatric gastroenterology fellowship programs in the United States and used CPT codes and endoscopy databases to determine the number of procedures performed at each institution during a 3-year period (2009–2011). They divided the number of procedures by the number of fellows at the institution to estimate the number of procedures performed by each fellow, and then compared these estimates to the NASPGHAN guidelines. From this sample of 12 fellowship programs, many did not have sufficient procedural volume to meet the requirements of the training guidelines. None of the programs met the minimum numbers from the 1999 guidelines. Although some of the requirements in the 2013 guidelines are less stringent, only 1 center met the thresholds for all procedures.

This article highlights the challenges in meeting the minimum number of procedures recommended during training, which is 1 step in achieving competence. As the guidelines note, many people will need to exceed these minimum numbers before they are competent in a given procedure. Objectively assessing competency is an unmet need, which theoretically could be accomplished through direct observation using an assessment tool. The well-known surgeon Atul Gawande wrote in The New Yorker about the importance of coaching and direct observation of surgeons in the operating room (4). Presumably, this concept could be adapted to procedural skills in gastroenterology. The NASPGHAN guideline from 2013 includes an assessment tool for endoscopy and colonoscopy. Quality metrics in adult gastroenterology include at least a 90% cecal intubation rate. As discussed in the NASPGHAN guidelines, these standards are based on studies of the learning curve in adult gastroenterology. For example, after 50 colonoscopies, trainees had cecal intubation rates exceeding 80% (5), but other studies have shown cecal intubation rates of 84% after 120 colonoscopies (6) and 90% after 140 colonoscopies (7). A larger regression analysis of 10 studies in adult gastroenterology fellows (n = 189) reported a 90% cecal intubation rate after 341 colonoscopies (8); however, little is known about the learning curve for procedural competence in pediatric gastroenterology, and defining competency in therapeutic endoscopy techniques is difficult.

In light of the challenges in meeting the minimum number of procedures suggested by NASPGHAN, the authors offer several suggestions to increase procedural experience. These include rotations with adult gastroenterologists, computer simulators, ex vivo animal models, and hands-on endoscopy courses. Only 25% of the pediatric gastroenterology fellowship programs they surveyed had a computer simulator, and logistical and scheduling constraints may make use difficult. Another instrument to complement traditional patient-based procedural training is the partial-task box trainer that has been developed and tested to teach endoscopy skills. This mechanical simulator is validated in pediatric gastroenterology and contains 5 elements that involve key endoscopic maneuvers (9). The modular system allows compartments to be interchanged to include additional skills, including advanced endoscopy and therapeutic techniques. The partial-task box trainer is affordable, as well as mobile, allowing fellows to use it when time permits. The box trainer is also useful in teaching basic endoscopic skills before novice fellows begin performing procedures on patients. In the future, simulators or the partial-task box trainer may be used to maintain procedural skills, improve skills for those who already have a more advanced skill set, or assess skills for licensing or credentialing purposes.

Because therapeutic endoscopic procedures are adapted to pediatric patients, fellowship training must use innovative methods to learn, maintain, and assess skills. The article by Lerner et al raises concerns that pediatric gastroenterology fellows may not be performing enough procedures during their training. We must be innovative and critically evaluate how best to provide high-quality, safe patient care for children who may benefit from endoscopic evaluation and therapy as well as assess the skills of individuals who are providing endoscopic care.

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